=====Clinic Prep===== .,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,., time: name: NL4: RFV: Checks: [] LDCT: [] PFTs: Results pending: [] Next Steps: [] =====Clinic Note ===== Assessment / Plan @@-year-old with history of x, initially admitted for X, now with x. @@ Recommendations - xxx - xxx Subjective - Environmental exposures: [ ] oil diffusers/scented candles/glade/Airwick plugins/incense sticks/ oil in humidifiers [ ] hot tub use [ ] pets/ birds at home [ ] playing any wind instruments [ ] hobbies such as wood working [ ] mold/water damage in the house Military-specific exposures: [ ] Agent orange - Vietnam War [ ] Depleted Uranium - Gulf War [ ] Asbestos - Navy due to shipyards [ ] Mustard gas – WWI [ ] Particulate matter [ ] Burn pit [ ] Chromium Occupational exposures outside the military : [ ] Asbestos - construction workers, elictricians, mining, railroad, fire fighters [ ] Ionizing radiation - uranium mining [ ] Vinyl chloride - pulp & paper workers [ ] Arsenic - smelting of ores, pesticide application, wood preservation [ ] Beryllium - ceramic workers, missile technicians, nuclear reactor workers, jewelers [ ] chromium - stainless steel production, welding, tanning industries [ ] Nickel - battery makers, ceramic makers, electroplaters, glass workers, jewelers, metal workers & welders, painters PMH: |ACTIVE PROBLEMS| Medications: |ACTIVE MEDICATIONS| Allergies: |ALLERGIES/ADR| |999Y1 PNEUMO| |999Y1 FLU,WHOLE| SH: Functional status: @@ [ ] fully independent in ADLs and IADLs [ ] uses cane at baseline [ ] uses walker at baseline [ ] uses wheelchair at baseline [ ] uses oxygen at baseline [ ] Tobacco Smoking – Age of onset of smoking: years Duration of smoking: years Maximum packs/day: Current cigarettes /day: Any alternate tobacco product [ ] cigar, [ ] pipe, [ ] waterpipe [ ] Vape/e cigarettes [ ] Second hand smoking [ ] Indoor emission from household combustion [ ] Outdoor air pollution ROS: Constitutional: No fevers, chills, sweats, weight change, or fatigue Eyes: No itchy, watery eyes, no blurry vision ENMT: No sinus/nasal congestion, rhinorrhea, post-nasal drip Skin: No Rash CV: No chest pain, palpitations, PND, orthopnea Respiratory: As above. GI: No heartburn MSK: No joint pains/myalgias Neuro: No numbness/tingling Objective Vitals: |VITALS| Exam: General: NAD, alert, WD, WN Eyes: PERRL, no scleral icterus ENMT: oropharynx clear, good dentition, no oral lesions, mallampati score @@ Skin: warm, intact, no rashes Neck: ROM and lymph node assessment LN: axillary, supra-clavicular, and inguinal lymph node assessment CV: RRR, no MRG, nl S1 and S2, no peripheral edema Resp: clear to auscultation bilaterally, no wheezes, rales, or rhonchi, normal effort, no clubbing/cyanosis Abdom: Normoactive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly Neuro: Awake alert oriented to person place time and situation Labs & Imaging: All labs and imaging within past 24 hr personally reviewed by me. |PFT | |CHEST 2 VIEWS PA&LAT| |CHEST CT| =====Clinic, Lung Mass===== Lung Mass Consult: Reason for Referral: Nodule / Mass in HPI: Environmental exposures: [ ] oil diffusers/scented candles/glade/Airwick plugins/incense sticks/ oil in humidifiers [ ] hot tub use [ ] pets/ birds at home [ ] playing any wind instruments [ ] hobbies such as wood working [ ] mold/water damage in the house PMH: |ACTIVE PROBLEMS| Medications: |ACTIVE MEDICATIONS| Allergies: |ALLERGIES/ADR| |999Y1 PNEUMO| |999Y1 FLU,WHOLE| SH: [ ] Tobacco Smoking – Age of onset of smoking: years Duration of smoking: years Maximum packs/day: Current cigarettes /day: Any alternate tobacco product [ ] cigar, [ ] pipe, [ ] waterpipe [ ] Vape/e cigarettes [ ] Second hand smoking [ ] Indoor emission from household combustion [ ] Outdoor air pollution Military-specific exposures: [ ] Agent orange - Vietnam War [ ] Depleted Uranium - Gulf War [ ] Asbestos - Navy due to shipyards [ ] Mustard gas – WWI [ ] Particulate matter [ ] Burn pit [ ] Chromium Occupational exposures outside the military : [ ] Asbestos - construction workers, elictricians, mining, railroad, fire fighters [ ] Ionizing radiation - uranium mining [ ] Vinyl chloride - pulp & paper workers [ ] Arsenic - smelting of ores, pesticide application, wood preservation [ ] Beryllium - ceramic workers, missile technicians, nuclear reactor workers, jewelers [ ] chromium - stainless steel production, welding, tanning industries [ ] Nickel - battery makers, ceramic makers, electroplaters, glass workers, jewelers, metal workers & welders, painters FH: [ ] Relatives with hx of lung cancer [ ] Relatives with other types of cancer [ ] Family history of lung disease: STOP-BANG Score: [ ] Snoring - do you snore loudly? [ ] Tired - do you feel tired, fatigued, or sleepy during daytime? [ ] Observed apneas? [ ] Pressure - hx of high blood pressure? [ ] BMI? [ ] Age > 50? [ ] Neck circumference: > 16 inch or 40 cm collar? [ ] Male Gender Hx of Anesthesia reactions: [ ] Prior surgeries and anesthesia reactions [ ] Hx of difficult intubation [ ] Family Hx of malignant hyperthermia ROS: Constitutional: No fevers, chills, sweats, weight change, or fatigue Eyes: No itchy, watery eyes, no blurry vision ENMT: No sinus/nasal congestion, rhinorrhea, post-nasal drip Skin: No Rash CV: No chest pain, palpitations, PND, orthopnea Respiratory: As above. GI: No heartburn MSK: No joint pains/myalgias Neuro: No numbness/tingling Exam: VS: |VITALS| General: NAD, alert, WD, WN Eyes: PERRL, no scleral icterus ENMT: oropharynx clear, good dentition, no oral lesions, mallampati score @@ Skin: warm, intact, no rashes Neck: ROM and lymph node assessment LN: axillary, supra-clavicular, and inguinal lymph node assessment CV: RRR, no MRG, nl S1 and S2, no peripheral edema Resp: clear to auscultation bilaterally, no wheezes, rales, or rhonchi, normal effort, no clubbing/cyanosis Abdom: Normoactive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly Neuro: Awake alert oriented to person place time and situation Data: |PFT | |CHEST 2 VIEWS PA&LAT| |CHEST CT| https://www.mdcalc.com/calc/3910/duke-activity-status-index-dasi ASA grade: [ ] ASA I - normal healthy patient [ ] ASA II - a patient with mild systemic disease [ ] ASA III - a patient with severe systemic disease [ ] ASA IV - a patient with severe systemic disease that is a constant threat to life Karnofsky Performance Status Scale (mdcalc.com) Assessment: Solitary Pulmonary Nodule Malignancy Risk (medscape.com) Plan: I discussed the above plan with the attending, Dr. Janaki Deepak. IP attending Dr. was also present to staff this patient